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AMC1 ATCO.AR.F.020 Aero-medical forms

Available versions for ERULES-1963177438-14597

ED Decision 2015/010/R found in: Air Traffic Controllers Licensing and Certification (2015/340) Part-ATCO (Jun 2024)

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AMC1 ATCO.AR.F.020  Aero-medical forms

ED Decision 2015/010/R

AERO-MEDICAL FORMS

The forms referred to in [ATCO.AR.F.020](#_DxCrossRefBm1379192658)
should reflect the information indicated in the following forms and
corresponding instructions for completion.

LOGO

CIVIL AVIATION ADMINISTRATION/MEMBER STATE

**APPLICATION FORM FOR
A MEDICAL CERTIFICATE**

MEDICAL IN
CONFIDENCE

Complete this page fully and in block capitals — Refer to
instructions for completion.

<table align="left" border="1" cellpadding="0" cellspacing="0" width="601">
<tr>
<td valign="top" width="198">
(1) State of licence
 issue:
</td>
<td colspan="5" valign="top" width="403">
(2) Medical
 certificate applied for: 
Class 1             o        Class 2             o         Class 3               o
</td>
<?if !supportMisalignedRows?>
</tr>
<tr>
<td valign="top" width="198">
(3) Surname:
</td>
<td colspan="3" valign="top" width="189">
(4) Previous
 surname(s):
</td>
<td colspan="2" valign="top" width="214">
(12) Application:
Initial   o 
 Revalidation/Renewal           o
</td>
<?if !supportMisalignedRows?>
</tr>
<tr>
<td valign="top" width="198">
(5) Forename(s):
</td>
<td colspan="2" valign="top" width="104">
(6) Date of birth
 (dd/mm/yyyy):
</td>
<td valign="top" width="85">
(7) Sex:
Male      o 
 Female  o
</td>
<td colspan="2" valign="top" width="214">
(13) Reference
 number:
</td>
<?if !supportMisalignedRows?>
</tr>
<tr>
<td valign="top" width="198">
(8) Place and
 country of birth:
</td>
<td colspan="3" valign="top" width="189">
(9) Nationality:
</td>
<td colspan="2" rowspan="2" valign="top" width="214">
(14) Type of licence
 applied for:
</td>
<?if !supportMisalignedRows?>
</tr>
<tr>
<td rowspan="4" valign="top" width="198">
(10) Permanent
 address:
Country:
Telephone No:
Mobile No:
E-mail:
</td>
<td colspan="3" rowspan="4" valign="top" width="189">
(11) Postal address
 (if different):
Country:
Telephone No:
</td>
<?if !supportMisalignedRows?>
</tr>
<tr>
<td colspan="2" valign="top" width="214">
(15) Occupation
 (principal):
</td>
<?if !supportMisalignedRows?>
</tr>
<tr>
<td colspan="2" valign="top" width="214">
(16) Employer:
</td>
<?if !supportMisalignedRows?>
</tr>
<tr>
<td colspan="2" valign="top" width="214">
(17) Last aero-medical
 examination:
Date:
Place:
</td>
<?if !supportMisalignedRows?>
</tr>
<tr>
<td colspan="2" valign="top" width="244">

 (18) Licence(s) held (type):
Licence(s)
 number(s):
</td>
<td colspan="4" valign="top" width="357">
(19) Any limitations
 on licence(s)/medical certificate held:
No        o
Yes       o         Details:
</td>
<?if !supportMisalignedRows?>
</tr>
<tr>
<td colspan="2" rowspan="2" valign="top" width="244">
(20) Have you ever
 had a medical certificate denied, suspended or revoked?
No        o
Yes       o         Date:               Country:
Details:
</td>
<td colspan="3" valign="top" width="152">
(21) Flight time
 total:
 
 Hrs                     n/a     o
</td>
<td valign="top" width="205">
(22) Flight time
 since last aero-medical examination: 
 Hrs                     n/a      o
</td>
<?if !supportMisalignedRows?>
</tr>
<tr>
<td colspan="4" valign="top" width="357">
(23) Aircraft class/type(s)
 currently flown:                n/a   o
</td>
<?if !supportMisalignedRows?>
</tr>
<tr>
<td colspan="2" rowspan="2" valign="top" width="244">
(24) Any aviation
 accident or reported incident since last aero-medical examination?
No        o         n/a      o
Yes       o         Date:               Place:
Details:
</td>
<td colspan="4" valign="top" width="357">
(25) Type of flying
 intended:                                        n/a   o
</td>
<?if !supportMisalignedRows?>
</tr>
<tr>
<td colspan="4" valign="top" width="357">
(26) Current pilot
 activity:    Single pilot  o            Multi-pilot  o
Current ATCO
 activity:          ADI  o      
 APS  o      ACS 
 o
</td>
<?if !supportMisalignedRows?>
</tr>
<tr>
<td colspan="2" valign="top" width="244">
(27) Do you drink
 alcohol?
No        o         Yes      o
 If yes, amount
</td>
<td colspan="4" rowspan="2" valign="top" width="357">
(28) Do you
 currently use any medication?
No        o         
Yes       o         state medication, dose, date started
 and why:
</td>
<?if !supportMisalignedRows?>
</tr>
<tr>
<td colspan="2" valign="top" width="244">
(29) Do you smoke
 tobacco?
No, never       o
No, stopped   o
 state date:
Yes                    o
 state type and amount:
</td>
<?if !supportMisalignedRows?>
</tr>
<tr height="0">
<td width="0"></td>
</tr>
</table>

**General and medical
history: Do you have, or have you ever had, any of the following? (Please
tick). If yes, give details in the remarks section (30).**

Yes  No
    Yes  No                                      Yes
No     Family
history of:  Yes  No

<table border="1" cellpadding="0" cellspacing="0" width="609">
<tr>
<td width="112">
101 Eye trouble/eye operation
</td>
<td width="14">
</td>
<td width="14">
</td>
<td width="126">
112 Nose, throat or speech disorder
</td>
<td width="15">
</td>
<td width="15">
</td>
<td width="130">
123 Malaria or other tropical disease
</td>
<td width="16">
</td>
<td width="15">
</td>
<td width="119">
170 Heart disease
</td>
<td valign="top" width="16">
</td>
<td valign="top" width="18">
</td>
<?if !supportMisalignedRows?>
<td width="0"></td>
</tr>
<tr>
<td rowspan="2" width="112">
102 Spectacles and/or contact lenses ever worn
</td>
<td rowspan="2" width="14">
</td>
<td rowspan="2" width="14">
</td>
<td width="126">
113 Head injury or concussion
</td>
<td width="15">
</td>
<td width="15">
</td>
<td width="130">
124 A positive HIV test
</td>
<td width="16">
</td>
<td width="15">
</td>
<td width="119">
171 High blood pressure
</td>
<td valign="top" width="16">
</td>
<td valign="top" width="18">
</td>
<?if !supportMisalignedRows?>
<td width="0"></td>
</tr>
<tr>
<td width="126">
114 Frequent or severe headaches
</td>
<td width="15">
</td>
<td width="15">
</td>
<td width="130">
125 Sexually transmitted disease
</td>
<td width="16">
</td>
<td width="15">
</td>
<td width="119">
172 High cholesterol level
</td>
<td valign="top" width="16">
</td>
<td valign="top" width="18">
</td>
<?if !supportMisalignedRows?>
<td width="0"></td>
</tr>
<tr>
<td rowspan="2" width="112">
103 Spectacle/contact lens prescriptions change since
 last medical exam.
</td>
<td rowspan="2" width="14">
</td>
<td rowspan="2" width="14">
</td>
<td width="126">
115 Dizziness or fainting spells
</td>
<td width="15">
</td>
<td width="15">
</td>
<td width="130">
126 Sleep disorder/apnoea syndrome
</td>
<td width="16">
</td>
<td width="15">
</td>
<td width="119">
173 Epilepsy
</td>
<td valign="top" width="16">
</td>
<td valign="top" width="18">
</td>
<?if !supportMisalignedRows?>
<td width="0"></td>
</tr>
<tr>
<td width="126">
116 Unconsciousness for any reason
</td>
<td width="15">
</td>
<td width="15">
</td>
<td width="130">
127 Musculoskeletal illness/impairment
</td>
<td width="16">
</td>
<td width="15">
</td>
<td width="119">
174 Mental illness
</td>
<td valign="top" width="16">
</td>
<td valign="top" width="18">
</td>
<?if !supportMisalignedRows?>
<td width="0"></td>
</tr>
<tr>
<td width="112">
104 Hay fever, other allergy
</td>
<td width="14">
</td>
<td width="14">
</td>
<td rowspan="2" width="126">
117 Neurological disorders: stroke, epilepsy, seizure,
 paralysis, etc.
</td>
<td rowspan="2" width="15">
</td>
<td rowspan="2" width="15">
</td>
<td width="130">
128 Any other illness or injury
</td>
<td width="16">
</td>
<td width="15">
</td>
<td width="119">
175 Diabetes
</td>
<td valign="top" width="16">
</td>
<td valign="top" width="18">
</td>
<?if !supportMisalignedRows?>
<td width="0"></td>
</tr>
<tr>
<td width="112">
105 Asthma, lung disease
</td>
<td width="14">
</td>
<td width="14">
</td>
<td width="130">
129 Admission to hospital
</td>
<td width="16">
</td>
<td width="15">
</td>
<td width="119">
176 Tuberculosis
</td>
<td valign="top" width="16">
</td>
<td valign="top" width="18">
</td>
<?if !supportMisalignedRows?>
<td width="0"></td>
</tr>
<tr>
<td width="112">
106 Heart or vascular trouble
</td>
<td width="14">
</td>
<td width="14">
</td>
<td rowspan="2" width="126">
118 Psychological/ psychiatric trouble of any sort
</td>
<td rowspan="2" width="15">
</td>
<td rowspan="2" width="15">
</td>
<td rowspan="2" width="130">
130 Visit to medical practitioner since last
 aero-medical examination
</td>
<td rowspan="2" width="16">
</td>
<td rowspan="2" width="15">
</td>
<td width="119">
177 Allergy/ asthma/eczema
</td>
<td valign="top" width="16">
</td>
<td valign="top" width="18">
</td>
<?if !supportMisalignedRows?>
</tr>
<tr>
<td width="112">
107 High or low blood pressure
</td>
<td width="14">
</td>
<td width="14">
</td>
<td width="119">
178 Inherited disorders
</td>
<td valign="top" width="16">
</td>
<td valign="top" width="18">
</td>
<?if !supportMisalignedRows?>
</tr>
<tr>
<td width="112">
108 Kidney stone or blood in urine
</td>
<td width="14">
</td>
<td width="14">
</td>
<td width="126">
119 Alcohol/drug/ substance abuse
</td>
<td width="15">
</td>
<td width="15">
</td>
<td width="130">
131 Refusal of life insurance
</td>
<td width="16">
</td>
<td width="15">
</td>
<td width="119">
179 Glaucoma
</td>
<td valign="top" width="16">
</td>
<td valign="top" width="18">
</td>
<?if !supportMisalignedRows?>
<td width="0"></td>
</tr>
<tr>
<td width="112">
109 Diabetes, hormone disorder
</td>
<td width="14">
</td>
<td width="14">
</td>
<td width="126">
120 Attempted suicide
</td>
<td width="15">
</td>
<td width="15">
</td>
<td width="130">
132 Refusal of pilot/ATCO licence
</td>
<td width="16">
</td>
<td width="15">
</td>
<td colspan="3" rowspan="2" valign="bottom" width="153">
Females only:
</td>
<?if !supportMisalignedRows?>
<td width="0"></td>
</tr>
<tr>
<td rowspan="2" width="112">
110 Stomach, liver or intestinal trouble
</td>
<td rowspan="2" width="14">
</td>
<td rowspan="2" width="14">
</td>
<td rowspan="2" width="126">
121 Motion sickness requiring medication
</td>
<td rowspan="2" width="15">
</td>
<td rowspan="2" width="15">
</td>
<td rowspan="2" width="130">
133 Medical rejection from or for military service
</td>
<td rowspan="2" width="16">
</td>
<td rowspan="2" width="15">
</td>
<?if !supportMisalignedRows?>
</tr>
<tr>
<td valign="bottom" width="119">
150 Gynaecological, menstrual problems
</td>
<td valign="bottom" width="16">
</td>
<td valign="bottom" width="18">
</td>
<?if !supportMisalignedRows?>
</tr>
<tr>
<td width="112">
111 Deafness, ear disorder
</td>
<td width="14">
</td>
<td width="14">
</td>
<td width="126">
122 Anaemia/sickle cell trait/other blood disorders
</td>
<td width="15">
</td>
<td width="15">
</td>
<td width="130">
134 Award of pension or compensation for injury or
 illness
</td>
<td width="16">
</td>
<td width="15">
</td>
<td width="119">
151 Are you pregnant?
</td>
<td valign="bottom" width="16">
</td>
<td valign="bottom" width="18">
</td>
<?if !supportMisalignedRows?>
</tr>
<tr>
<td colspan="12" valign="top" width="609">
(30) Remarks: If previously reported and no change
 since, so state.
</td>
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</tr>
<tr>
<td colspan="12" valign="top" width="609">
(31) Declaration: I hereby declare that I have
 carefully considered the statements made above and to the best of my belief
 they are complete and correct and that I have not withheld any relevant
 information or made any misleading statements. I understand that if I have
 made any false or misleading statements in connection with this application,
 or fail to release the supporting medical information, the licensing
 authority may refuse to grant me a medical certificate or may withdraw any
 medical certificate granted, without prejudice to any other action
 applicable under national law. 
CONSENT TO RELEASE OF MEDICAL INFORMATION: I hereby
 authorise the release of all information contained in this report and any or
 all attachments to the AME and, where necessary, to the medical assessor of
 the licensing authority, recognising that these documents or electronically
 stored data are to be used for completion of a medical assessment and will
 become and remain the property of the licensing authority, providing that I
 or my physician may have access to them according to national law. Medical confidentiality
 will be respected at all times.
------------------------------------          --------------------------------------------              --------------------------------------------
                    Date                                           Signature of applicant                    Signature of AME/(medical assessor)
</td>
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<td width="0"></td>
</tr>
</table>

INSTRUCTIONS
FOR COMPLETION OF THE APPLICATION FORM FOR A MEDICAL CERTIFICATE

This application form and all attached report forms will be
transmitted to the licensing authority. Medical confidentiality shall be
respected at all times.

The applicant should personally complete, in full, all
questions (sections) on the application form. Writing should be legible and in
block capitals, using a ball-point pen. Completion of this form by
typing/printing is also acceptable. If more space is required to answer any
questions, a plain sheet of paper should be used, bearing the applicant’s name
and signature, and the date of signing. The following numbered instructions
apply to the numbered headings on the application form for a medical certificate.

Failure to complete the application form in full, or to
write legibly, may result in non-acceptance of the application form. The
making of false or misleading statements or the withholding of relevant
information in respect of this application may result in criminal prosecution,
denial of this application and/or withdrawal of any medical certificate(s)
granted

<table border="1" cellpadding="0" cellspacing="0" width="604">
<tr>
<td valign="top" width="264">
1.         LICENSING
 AUTHORITY:
State name of country this application is to be
 forwarded to.
</td>
<td valign="top" width="340">
17.       LAST
 APPLICATION FOR A MEDICAL CERTIFICATE:
State date (day, month, year) and place (town,
 country). 
 Initial applicants state ‘NONE’.
</td>
<?if !supportMisalignedRows?>
<td width="0"></td>
</tr>
<tr>
<td valign="top" width="264">
2.         MEDICAL
 CERTIFICATE APPLIED FOR:
Tick appropriate box.
Class 1: Professional Pilot
Class 2: Private Pilot 
Class 3: Air Traffic Controller
</td>
<td valign="top" width="340">
18.       LICENCE(S)
 HELD (TYPE):
State type of licence(s) held. 
Enter licence number and State of issue. 
If no licences are held, state ‘NONE’.
</td>
<?if !supportMisalignedRows?>
</tr>
<tr>
<td valign="top" width="264">
3.         SURNAME:
State surname/family name.
</td>
<td valign="top" width="340">
19.       ANY
 LIMITATIONS ON THE LICENCE(S)/MEDICAL CERTIFICATE:
Tick appropriate box and give details of any
 limitations on your licence(s)/medical certificate, e.g. vision, colour
 vision, safety pilot, etc.
</td>
<?if !supportMisalignedRows?>
</tr>
<tr>
<td valign="top" width="264">
4.         PREVIOUS
 SURNAME(S):
If your surname or family name has changed for any
 reason, state previous name(s).
</td>
<td valign="top" width="340">
20.       MEDICAL
 CERTIFICATE DENIAL, SUSPENSION OR REVOCATION:
Tick ‘YES’ box if you have ever had a medical
 certificate denied, suspended or revoked, even if only temporary.
If ‘YES’, state date (dd/mm/yyyy) and country where it
 occurred.
</td>
<?if !supportMisalignedRows?>
</tr>
<tr>
<td valign="top" width="264">
5.         FORENAME(S):
State first and middle names (maximum three).
</td>
<td valign="top" width="340">
21.       FLIGHT
 TIME TOTAL:
State total number of hours flown or, for ATCO’s tick
 n/a box.
</td>
<?if !supportMisalignedRows?>
</tr>
<tr>
<td valign="top" width="264">
6.         DATE OF
 BIRTH: 
Specify in order dd/mm/yyyy.
</td>
<td valign="top" width="340">
22.       FLIGHT
 TIME SINCE LAST MEDICAL:
State number of hours flown since your last
 aero-medical examination or, for ATCO’s tick n/a box.
</td>
<?if !supportMisalignedRows?>
</tr>
<tr>
<td valign="top" width="264">
7.         SEX:
Tick appropriate box.
</td>
<td valign="top" width="340">
23.       AIRCRAFT
 CLASS/TYPE(S) CURRENTLY FLOWN:
State name of principal aircraft flown, e.g. Boeing
 737, Cessna 150, etc. or, for ATCO’s tick n/a box.
</td>
<?if !supportMisalignedRows?>
</tr>
<tr>
<td valign="top" width="264">
8.         PLACE AND
 COUNTRY OF BIRTH:
State town and country of birth.
</td>
<td valign="top" width="340">
24.       ANY
 AVIATION ACCIDENT OR REPORTED INCIDENT SINCE LAST AERO-MEDICAL EXAMINATION:
If ‘YES’ box ticked, state date (dd/mm/yyyy) and
 country of accident/incident.
</td>
<?if !supportMisalignedRows?>
</tr>
<tr>
<td valign="top" width="264">
9.         NATIONALITY:
State name of country of citizenship.
</td>
<td valign="top" width="340">
25.       TYPE OF
 FLYING INTENDED:
State whether airline, charter, single pilot,
 commercial air transport, carrying passengers, agriculture, pleasure, etc.,
 or, for ATCO’s tick n/a box.
</td>
<?if !supportMisalignedRows?>
</tr>
<tr>
<td valign="top" width="264">
10.       PERMANENT
 ADDRESS:
State permanent postal address and country. Enter
 telephone area code as well as telephone number.
</td>
<td valign="top" width="340">
26.       CURRENT
 PILOT/ATCO ACTIVITY:
Tick appropriate box to indicate whether you fly as the
 SOLE pilot or not or, for ATCO’s whether you operate as tower, radar or
 other. 
</td>
<?if !supportMisalignedRows?>
</tr>
<tr>
<td valign="top" width="264">
11.       POSTAL
 ADDRESS (IF DIFFERENT):
If different from permanent address, state full current
 postal address including telephone number and area code. If the same, enter
 ‘SAME’.
</td>
<td valign="top" width="340">
27.       DO YOU DRINK
 ALCOHOL?
Tick applicable box. If yes, state weekly alcohol
 consumption, 
 e.g. 2 litres beer.
</td>
<?if !supportMisalignedRows?>
</tr>
<tr>
<td valign="top" width="264">
12.       APPLICATION:
Tick appropriate box.
</td>
<td valign="top" width="340">
28.       DO YOU
 CURRENTLY USE ANY MEDICATION?
If ‘YES’, give full details — name, how much you take
 and when, etc. 
Include any non-prescription medication. 
</td>
<?if !supportMisalignedRows?>
</tr>
<tr>
<td valign="top" width="264">
13.       REFERENCE
 NUMBER:
State reference number allocated to you by the
 licensing authority.
Initial applicants enter ‘NONE’.
</td>
<td valign="top" width="340">
29.       DO YOU
 SMOKE TOBACCO?
Tick applicable box. Current smokers state type
 (cigarettes, cigars, pipe) and amount (e.g. 2 cigars daily; pipe — 1 oz.
 weekly).
</td>
<?if !supportMisalignedRows?>
</tr>
<tr>
<td rowspan="2" valign="top" width="264">
14.       TYPE OF
 LICENCE APPLIED FOR:
State type of licence applied for from the following
 list:
—            
 Aeroplane Transport Pilot
 Licence
—            
 Multi-Pilot Licence
—            
 Commercial Pilot
 Licence/Instrument Rating
—            
 Commercial Pilot Licence
—            
 Air Traffic Controller
 Licence
—            
 Private Pilot
 Licence/Instrument Rating
—            
 Private Pilot Licence
—            
 Sailplane Pilot Licence
—            
 Balloon Pilot Licence
—            
 and whether Fixed Wing/Rotary Wing/Both
</td>
<td valign="top" width="340">
GENERAL AND MEDICAL HISTORY
All items under this heading from number 101 to 179
 inclusive should have the answer ‘YES’ or ‘NO’ ticked. You should tick ‘YES’
 if you have ever had the condition in your life and describe the condition
 and approximate date in the (30) remarks section. All questions asked are
 medically important even though this may not be readily apparent.
Items numbered 170 to 179 relate to immediate family
 history, whereas items numbered 150 to 151 should be answered by female
 applicants only.
If information has been reported on a previous
 application form for a medical certificate and there has been no change in
 your condition, you may state ‘Previously reported; no change since’.
 However, you should still tick ‘YES’ to the condition.
Do not report occasional common illnesses such as
 colds.
</td>
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</tr>
<tr>
<td rowspan="3" valign="top" width="340">
31.       DECLARATION
 AND CONSENT TO OBTAINING AND RELEASING INFORMATION:
Do not sign or date these declarations until indicated
 to do so by the AME who will act as witness and sign accordingly.
</td>
<?if !supportMisalignedRows?>
</tr>
<tr>
<td valign="top" width="264">
15.       OCCUPATION
 (PRINCIPAL):
Indicate your principal employment.
</td>
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</tr>
<tr>
<td valign="top" width="264">
16.       EMPLOYER:
If principal occupation is pilot/ATCO, then state
 employer’s name or if self-employed as a pilot, state ‘self’.
</td>
<?if !supportMisalignedRows?>
</tr>
</table>

AERO-MEDICAL EXAMINATION REPORT FORM FOR
CLASS 1, CLASS 2 & CLASS 3 APPLICANTS

<table align="left" border="0" cellpadding="0" cellspacing="0" width="604">
<tr>
<td rowspan="2" valign="top" width="179">
(201) Examination
 category  
Initial   o
Revalidation   o    Renewal 
 o
</td>
<td rowspan="2" valign="top" width="47">
(202) Height
(cm)
</td>
<td rowspan="2" valign="top" width="51">
(203) Weight
(kg)
</td>
<td rowspan="2" valign="top" width="46">
(204) Colour eye
</td>
<td rowspan="2" valign="top" width="46">
(205) Colour hair
</td>
<td colspan="2" rowspan="2" valign="top" width="112">
(206) Blood pressure —
 seated (mmHg)
</td>
<td colspan="2" valign="top" width="123">
(207) Pulse — resting
</td>
<?if !supportMisalignedRows?>
</tr>
<tr>
<td rowspan="2" valign="top" width="44">
Rate (bpm)
</td>
<td rowspan="2" valign="top" width="79">
Rhythm:
regular     o
irregular   o
</td>
<?if !supportMisalignedRows?>
</tr>
<tr>
<td valign="top" width="179">
Referral           o
</td>
<td valign="top" width="47">
</td>
<td valign="top" width="51">
</td>
<td valign="top" width="46">
</td>
<td valign="top" width="46">
</td>
<td valign="top" width="53">
Systolic
</td>
<td valign="top" width="59">
Diastolic
</td>
<?if !supportMisalignedRows?>
<td width="0"></td>
</tr>
<tr height="0">
<td width="0"></td>
</tr>
</table>

Clinical
exam: Check each item           Normal  Abnormal                                                           Normal
Abnormal

<table border="1" cellpadding="0" cellspacing="0" width="604">
<tr>
<td valign="top" width="239">
(208) Head, face, neck, scalp
</td>
<td valign="top" width="28">
</td>
<td valign="top" width="28">
</td>
<td valign="top" width="253">
(218) Abdomen, hernia, liver, spleen
</td>
<td valign="top" width="28">
</td>
<td valign="top" width="28">
</td>
</tr>
<tr>
<td valign="top" width="239">
(209) Mouth, throat, teeth, voice, speech
</td>
<td valign="top" width="28">
</td>
<td valign="top" width="28">
</td>
<td valign="top" width="253">
(219) Anus, rectum
</td>
<td valign="top" width="28">
</td>
<td valign="top" width="28">
</td>
</tr>
<tr>
<td valign="top" width="239">
(210) Nose, sinuses
</td>
<td valign="top" width="28">
</td>
<td valign="top" width="28">
</td>
<td valign="top" width="253">
(220) Genito-urinary system
</td>
<td valign="top" width="28">
</td>
<td valign="top" width="28">
</td>
</tr>
<tr>
<td valign="top" width="239">
(211) Ears, drums, eardrum motility
</td>
<td valign="top" width="28">
</td>
<td valign="top" width="28">
</td>
<td valign="top" width="253">
(221) Endocrine system
</td>
<td valign="top" width="28">
</td>
<td valign="top" width="28">
</td>
</tr>
<tr>
<td valign="top" width="239">
(212) Eyes — orbit &amp; adnexa; visual fields
</td>
<td valign="top" width="28">
</td>
<td valign="top" width="28">
</td>
<td valign="top" width="253">
(222) Upper &amp; lower limbs, joints
</td>
<td valign="top" width="28">
</td>
<td valign="top" width="28">
</td>
</tr>
<tr>
<td valign="top" width="239">
(213) Eyes — pupils and optic fundi
</td>
<td valign="top" width="28">
</td>
<td valign="top" width="28">
</td>
<td valign="top" width="253">
(223) Spine, other musculoskeletal
</td>
<td valign="top" width="28">
</td>
<td valign="top" width="28">
</td>
</tr>
<tr>
<td valign="top" width="239">
(214) Eyes — ocular motility; nystagmus
</td>
<td valign="top" width="28">
</td>
<td valign="top" width="28">
</td>
<td valign="top" width="253">
(224) Neurologic — reflexes, etc.
</td>
<td valign="top" width="28">
</td>
<td valign="top" width="28">
</td>
</tr>
<tr>
<td valign="top" width="239">
(215) Lungs, chest, breasts
</td>
<td valign="top" width="28">
</td>
<td valign="top" width="28">
</td>
<td valign="top" width="253">
(225) Psychiatric
</td>
<td valign="top" width="28">
</td>
<td valign="top" width="28">
</td>
</tr>
<tr>
<td valign="top" width="239">
(216) Heart
</td>
<td valign="top" width="28">
</td>
<td valign="top" width="28">
</td>
<td valign="top" width="253">
(226) Skin, identifying marks and lymphatics
</td>
<td valign="top" width="28">
</td>
<td valign="top" width="28">
</td>
</tr>
<tr>
<td valign="top" width="239">
(217) Vascular system
</td>
<td valign="top" width="28">
</td>
<td valign="top" width="28">
</td>
<td valign="top" width="253">
(227) General systemic
</td>
<td valign="top" width="28">
</td>
<td valign="top" width="28">
</td>
</tr>
<tr>
<td colspan="6" valign="top" width="604">
(228) Notes: Describe every abnormal finding. Enter
 applicable item number before each comment.
</td>
</tr>
</table>

Visual acuity

(229) Distant vision                                                              (236) Pulmonary function
(237) Haemoglobin

<table border="0" cellpadding="0" cellspacing="0" width="605">
<tr>
<td colspan="2" valign="top" width="61">
</td>
<td colspan="3" valign="top" width="64">
Uncorrected
</td>
<td colspan="6" valign="top" width="55">
</td>
<td colspan="6" width="54">
Spectacles
</td>
<td width="44">
Contact lenses
</td>
<td valign="top" width="16">
</td>
<td colspan="5" valign="top" width="194">
FEV1/FVC   __________   
 %
</td>
<td colspan="3" valign="top" width="118">
   ____________        ______ 
 (unit)
</td>
</tr>
<tr>
<td colspan="2" valign="top" width="61">
Right eye
</td>
<td colspan="3" valign="top" width="64">
</td>
<td colspan="6" valign="top" width="55">
Corr. to
</td>
<td colspan="6" valign="top" width="54">
</td>
<td valign="top" width="44">
</td>
<td valign="top" width="16">
</td>
<td colspan="5" valign="top" width="194">
</td>
<td colspan="3" valign="top" width="118">
</td>
</tr>
<tr>
<td colspan="2" valign="top" width="61">
Left eye
</td>
<td colspan="3" valign="top" width="64">
</td>
<td colspan="6" valign="top" width="55">
Corr. to 
</td>
<td colspan="6" valign="top" width="54">
</td>
<td valign="top" width="44">
</td>
<td rowspan="2" valign="top" width="16">
</td>
<td colspan="5" rowspan="2" valign="top" width="194">
Normal     o         
 Abnormal   o
</td>
<td colspan="3" rowspan="2" valign="top" width="118">
Normal      o            
 Abnormal   o
</td>
</tr>
<tr>
<td colspan="2" valign="top" width="61">
Both eyes
</td>
<td colspan="3" valign="top" width="64">
</td>
<td colspan="6" valign="top" width="55">
Corr. to
</td>
<td colspan="6" valign="top" width="54">
</td>
<td valign="top" width="44">
</td>
</tr>
<tr>
<td colspan="11" valign="top" width="180">
</td>
<td colspan="7" valign="top" width="98">
</td>
<td valign="top" width="16">
</td>
<td colspan="8" valign="top" width="312">
(235) Urinalysis        Normal   o           Abnormal 
 o
</td>
</tr>
<tr>
<td colspan="3" valign="top" width="95">
(230) Intermediate vision
</td>
<td colspan="8" width="85">
Uncorrected
</td>
<td colspan="7" width="98">
Corrected
</td>
<td valign="top" width="16">
</td>
<td valign="top" width="82">
Glucose
</td>
<td colspan="2" valign="top" width="76">
Protein
</td>
<td colspan="3" valign="top" width="76">
Blood
</td>
<td colspan="2" valign="top" width="76">
Other
</td>
</tr>
<tr>
<td colspan="3" valign="top" width="95">
</td>
<td colspan="3" valign="top" width="43">
Yes
</td>
<td colspan="5" valign="top" width="43">
No
</td>
<td colspan="4" valign="top" width="49">
Yes
</td>
<td colspan="3" valign="top" width="49">
No
</td>
<td valign="top" width="16">
</td>
<td valign="top" width="82">
</td>
<td colspan="2" valign="top" width="76">
</td>
<td colspan="3" valign="top" width="76">
</td>
<td colspan="2" valign="top" width="76">
</td>
</tr>
<tr>
<td colspan="3" valign="top" width="95">
Right eye
</td>
<td colspan="3" valign="top" width="43">
</td>
<td colspan="5" valign="top" width="43">
</td>
<td colspan="4" valign="top" width="49">
</td>
<td colspan="3" valign="top" width="49">
</td>
<td valign="top" width="16">
</td>
<td colspan="8" valign="top" width="312">
Accompanying reports
</td>
</tr>
<tr>
<td colspan="3" valign="top" width="95">
Left eye
</td>
<td colspan="3" valign="top" width="43">
</td>
<td colspan="5" valign="top" width="43">
</td>
<td colspan="4" valign="top" width="49">
</td>
<td colspan="3" valign="top" width="49">
</td>
<td valign="top" width="16">
</td>
<td colspan="2" valign="top" width="124">
</td>
<td colspan="2" width="69">
Not performed
</td>
<td colspan="3" width="50">
Normal
</td>
<td width="68">
Abnormal/Comment
</td>
</tr>
<tr>
<td colspan="3" valign="top" width="95">
Both eyes
</td>
<td colspan="3" valign="top" width="43">
</td>
<td colspan="5" valign="top" width="43">
</td>
<td colspan="4" valign="top" width="49">
</td>
<td colspan="3" valign="top" width="49">
</td>
<td valign="top" width="16">
</td>
<td colspan="2" valign="top" width="124">
(238) ECG
</td>
<td colspan="2" valign="top" width="69">
</td>
<td colspan="3" valign="top" width="50">
</td>
<td valign="top" width="68">
</td>
</tr>
<tr>
<td colspan="3" valign="top" width="95">
</td>
<td colspan="8" valign="top" width="85">
</td>
<td colspan="7" valign="top" width="98">
</td>
<td valign="top" width="16">
</td>
<td colspan="2" valign="top" width="124">
(239) Audiogram
</td>
<td colspan="2" valign="top" width="69">
</td>
<td colspan="3" valign="top" width="50">
</td>
<td valign="top" width="68">
</td>
</tr>
<tr>
<td colspan="3" valign="top" width="95">
(231) Near vision
</td>
<td colspan="8" width="85">
Uncorrected
</td>
<td colspan="7" width="98">
Corrected
</td>
<td valign="top" width="16">
</td>
<td colspan="2" valign="top" width="124">
(240) Ophthalmology
</td>
<td colspan="2" valign="top" width="69">
</td>
<td colspan="3" valign="top" width="50">
</td>
<td valign="top" width="68">
</td>
</tr>
<tr>
<td colspan="3" valign="top" width="95">
</td>
<td colspan="3" width="43">
Yes
</td>
<td colspan="5" width="43">
No
</td>
<td colspan="4" width="49">
Yes
</td>
<td colspan="3" width="49">
No
</td>
<td valign="top" width="16">
</td>
<td colspan="2" valign="top" width="124">
(241) ORL (ENT)
</td>
<td colspan="2" valign="top" width="69">
</td>
<td colspan="3" valign="top" width="50">
</td>
<td valign="top" width="68">
</td>
</tr>
<tr>
<td colspan="3" valign="top" width="95">
Right eye
</td>
<td colspan="3" valign="top" width="43">
</td>
<td colspan="5" valign="top" width="43">
</td>
<td colspan="4" valign="top" width="49">
</td>
<td colspan="3" valign="top" width="49">
</td>
<td valign="top" width="16">
</td>
<td colspan="2" valign="top" width="124">
(242) Blood lipids
</td>
<td colspan="2" valign="top" width="69">
</td>
<td colspan="3" valign="top" width="50">
</td>
<td valign="top" width="68">
</td>
</tr>
<tr>
<td colspan="3" valign="top" width="95">
Left eye
</td>
<td colspan="3" valign="top" width="43">
</td>
<td colspan="5" valign="top" width="43">
</td>
<td colspan="4" valign="top" width="49">
</td>
<td colspan="3" valign="top" width="49">
</td>
<td valign="top" width="16">
</td>
<td colspan="2" valign="top" width="124">
(243) Pulmonary function
</td>
<td colspan="2" valign="top" width="69">
</td>
<td colspan="3" valign="top" width="50">
</td>
<td valign="top" width="68">
</td>
</tr>
<tr>
<td colspan="3" valign="top" width="95">
Both eyes
</td>
<td colspan="3" valign="top" width="43">
</td>
<td colspan="5" valign="top" width="43">
</td>
<td colspan="4" valign="top" width="49">
</td>
<td colspan="3" valign="top" width="49">
</td>
<td valign="top" width="16">
</td>
<td colspan="2" rowspan="2" valign="top" width="124">
(244) Other (what?)
</td>
<td colspan="2" rowspan="2" valign="top" width="69">
</td>
<td colspan="3" rowspan="2" valign="top" width="50">
</td>
<td rowspan="2" valign="top" width="68">
</td>
</tr>
<tr>
<td colspan="8" valign="top" width="147">
(232) Spectacles
</td>
<td colspan="10" valign="top" width="130">
(233) Contact lenses
</td>
<td valign="top" width="16">
</td>
</tr>
<tr>
<td colspan="8" valign="top" width="147">
Yes   o            
 No  o
</td>
<td colspan="10" valign="top" width="130">
Yes  o         
 No  o
</td>
<td valign="top" width="16">
</td>
<td colspan="8" valign="top" width="312">
</td>
</tr>
<tr>
<td colspan="8" valign="top" width="147">
Type:
</td>
<td colspan="10" valign="top" width="130">
Type:
</td>
<td valign="top" width="16">
</td>
<td colspan="8" valign="top" width="312">
(247) AME recommendation:
</td>
</tr>
<tr>
<td colspan="3" width="95">
Refraction
</td>
<td colspan="4" width="46">
Sph
</td>
<td colspan="5" width="46">
Cyl
</td>
<td colspan="4" width="46">
Axis
</td>
<td colspan="2" width="46">
Add
</td>
<td valign="top" width="16">
</td>
<td colspan="8" valign="top" width="312">
Name of applicant:  
 Date of birth:   Reference
 number: 
</td>
</tr>
<tr>
<td colspan="3" valign="top" width="95">
Right eye
</td>
<td colspan="4" valign="top" width="46">
</td>
<td colspan="5" valign="top" width="46">
</td>
<td colspan="4" valign="top" width="46">
</td>
<td colspan="2" valign="top" width="46">
</td>
<td valign="top" width="16">
</td>
<td colspan="8" valign="top" width="312">
--------------------------   -----------------   ---------------------------
</td>
</tr>
<tr>
<td colspan="3" valign="top" width="95">
Left eye
</td>
<td colspan="4" valign="top" width="46">
</td>
<td colspan="5" valign="top" width="46">
</td>
<td colspan="4" valign="top" width="46">
</td>
<td colspan="2" valign="top" width="46">
</td>
<td valign="top" width="16">
</td>
<td colspan="8" valign="top" width="312">
o   Fit for
 class:         --------------------
</td>
</tr>
<tr>
<td colspan="8" valign="top" width="147">
(313) Colour vision
</td>
<td colspan="10" valign="top" width="130">
Normal  o 
 Abnormal o
</td>
<td valign="top" width="16">
</td>
<td colspan="8" valign="top" width="312">
o   Medical certificate issued by undersigned
 (copy attached) for class:   -------------------------------
</td>
</tr>
<tr>
<td colspan="11" valign="top" width="180">
Colour vision testing method/s:
</td>
<td colspan="7" valign="top" width="98">
</td>
<td valign="top" width="16">
</td>
<td colspan="8" valign="top" width="312">
o   Unfit for
 class:     --------------------
</td>
</tr>
<tr>
<td colspan="11" valign="top" width="180">
Results:
</td>
<td colspan="7" valign="top" width="98">
</td>
<td valign="top" width="16">
</td>
<td colspan="8" valign="top" width="312">
o   Deferred
 for further evaluation. If yes, why and to whom?
</td>
</tr>
<tr>
<td colspan="9" valign="top" width="161">
(234) Hearing
(when 239/241 not performed)
</td>
<td colspan="4" valign="bottom" width="62">
Right ear
</td>
<td colspan="5" valign="bottom" width="54">
Left ear
</td>
<td valign="top" width="16">
</td>
<td colspan="8" valign="top" width="312">
(248) Comments, limitations
</td>
</tr>
<tr>
<td colspan="9" rowspan="2" valign="top" width="161">
Conversational voice test (2m) with back turned to
 examiner
</td>
<td colspan="4" valign="top" width="62">
Yes   o
No    o
</td>
<td colspan="5" valign="top" width="54">
Yes   o
No    o
</td>
<td valign="top" width="16">
</td>
<td colspan="8" valign="top" width="312">
</td>
</tr>
<tr>
<td colspan="4" valign="top" width="62">
</td>
<td colspan="5" valign="top" width="54">
</td>
<td valign="top" width="16">
</td>
<td colspan="8" valign="top" width="312">
</td>
</tr>
<tr>
<td colspan="18" valign="top" width="277">
Audiometry
</td>
<td colspan="9" width="328"></td>
</tr>
<tr>
<td valign="top" width="50">
Hz
</td>
<td colspan="3" width="57">
500
</td>
<td colspan="6" width="58">
1000
</td>
<td colspan="4" width="59">
2000
</td>
<td colspan="4" width="53">
3000
</td>
<td colspan="9" width="328"></td>
</tr>
<tr>
<td valign="top" width="50">
Right
</td>
<td colspan="3" valign="top" width="57">
</td>
<td colspan="6" valign="top" width="58">
</td>
<td colspan="4" valign="top" width="59">
</td>
<td colspan="4" valign="top" width="53">
</td>
<td colspan="9" width="328"></td>
</tr>
<tr>
<td valign="top" width="50">
Left
</td>
<td colspan="3" valign="top" width="57">
</td>
<td colspan="6" valign="top" width="58">
</td>
<td colspan="4" valign="top" width="59">
</td>
<td colspan="4" valign="top" width="53">
</td>
<td colspan="9" width="328"></td>
</tr>
<tr height="0">
</tr>
</table>

(249) AME declaration:

<table border="0" cellpadding="0" cellspacing="0" width="605">
<tr>
<td colspan="3" valign="top" width="605">
I hereby certify that I/my AME group have personally
 examined the applicant named on this aero-medical examination report and
 that this report with any attachment embodies my findings completely and
 correctly.
</td>
</tr>
<tr>
<td valign="top" width="198">
(250) Place and date:
</td>
<td valign="top" width="255">
AME name and address:
</td>
<td valign="top" width="151">
AME certificate No: 
</td>
</tr>
<tr>
<td valign="top" width="198">
AME signature:
</td>
<td valign="top" width="255">
E-mail:
</td>
<td valign="top" width="151">
</td>
</tr>
<tr>
<td valign="top" width="198">
</td>
<td valign="top" width="255">
Telephone No:
Telefax No:
</td>
<td valign="top" width="151">
</td>
</tr>
</table>

INSTRUCTIONS FOR COMPLETION OF THE
AERO-MEDICAL EXAMINATION REPORT FORMS

The AME performing the aero-medical examination
should verify the identity of the applicant.

All questions (sections) on the aero-medical
examination report form should be completed in full. If an otorhinolaryngology
examination report form is attached, then questions 209, 210, 211, and 234 may
be omitted. If an ophthalmology examination report form is attached, then
questions 212, 213, 214, 229, 230, 231, 232, and 233 may be omitted.

Writing should be legible and in block capitals
using a ball-point pen. Completion of this form by typing/printing is also
acceptable. If more space is required to answer any question, a plain sheet of
paper should be used, bearing the applicant’s name, the AME’s name and
signature, and the date of signing. The following numbered instructions apply
to the numbered headings on the aero-medical examination report form.

Failure to complete the aero-medical examination
report form in full, as required, or to write legibly, may result in
non-acceptance of the application in total and may lead to withdrawal of any
medical certificate issued. The making of false or misleading statements or
the withholding of relevant information by an AME may result in criminal
prosecution, denial of an application or withdrawal of any medical
certificate(s) granted.

201      EXAMINATION
CATEGORY — Tick appropriate box.

Initial — Initial examination for either class 1, 2
or 3; also initial examination for upgrading from class 2 to 1 (notate
‘upgrading’ in box 248).

Renewal/Revalidation —Subsequent ROUTINE
examinations.

202      HEIGHT
— Measure height, without shoes, in centimetres to nearest cm.

203      WEIGHT
— Measure weight, in indoor clothes, in kilograms to nearest kg.

204      COLOUR
EYE — State colour of applicant’s eyes from the following list: brown, blue,
green, hazel, grey, multi.

205      COLOUR
HAIR — State colour of applicant’s hair from the following list: brown, black,
red, fair, bald.

206      BLOOD
PRESSURE — Blood pressure readings should be recorded as Phase 1 for systolic
pressure and Phase 5 for diastolic pressure. The applicant should be seated
and rested. Recordings in mm Hg.

207      PULSE
(RESTING) — The pulse rate should be recorded in beats per minute and the
rhythm should be recorded as regular or irregular. Further comments if
necessary may be written in section 228, 248 or separately.

208 to 227 inclusive constitute the general
clinical examination, and each of the boxes should be marked (with a tick) as
normal or abnormal.

208      HEAD,
FACE, NECK, SCALP — To include appearance, range of neck and facial movements,
symmetry, etc.

209      MOUTH,
THROAT, TEETH, VOICE, SPEECH — To include voice and speech quality and
appearance of buccal cavity, palate motility, tonsillar area, pharynx and also
gums, teeth and tongue.

210      NOSE,
SINUSES — To include appearance and any evidence of nasal obstruction or sinus
tenderness on palpation.

211      EARS,
DRUMS, EARDRUM MOTILITY — To include otoscopy of external ear, canal, tympanic
membrane. Eardrum motility by valsalva manoeuvre or by pneumatic otoscopy.

212      EYES
— ORBIT AND ADNEXA; VISUAL FIELDS — To include appearance, position and
movement of eyes and their surrounding structures in general, including
eyelids and conjunctiva. Visual fields check by campimetry, perimetry or
confrontation.

213      EYES
— PUPILS AND OPTIC FUNDI — To include appearance, size, reflexes, red reflex
and fundoscopy. Special note of corneal scars.

214      EYES
— OCULAR MOTILITY, NYSTAGMUS — To include range of movement of eyes in all
directions; symmetry of movement of both eyes; ocular muscle balance;
convergence; accommodation; signs of nystagmus.

215      LUNGS,
CHEST, BREASTS — To include inspection of chest for deformities, operation
scars, abnormality of respiratory movement, auscultation of breath sounds.
Physical examination of female applicant’s breasts should only be performed
with informed consent.

216      HEART
— To include apical heartbeat, position, auscultation for murmurs, carotid
bruits, palpation for trills.

217      VASCULAR
SYSTEM — To include examination for varicose veins, character and feel of
pulse, peripheral pulses, evidence of peripheral circulatory disease.

218      ABDOMEN,
HERNIA, LIVER, SPLEEN — To include inspection of abdomen; palpation of
internal organs; check for inquinal hernias in particular.

219      ANUS,
RECTUM — Examination only with informed consent.

220      GENITO-URINARY
SYSTEM — To include renal palpation; inspection palpation male/female
reproductive organs only with informed consent.

221      ENDOCRINE
SYSTEM — To include inspection, palpation for evidence of hormonal
abnormalities/imbalance; thyroid gland.

222      UPPER
AND LOWER LIMBS, JOINTS — To include full range of movements of joints and
limbs, any deformities, weakness or loss. Evidence of arthritis.

223      SPINE,
OTHER MUSCULOSKELETAL — To include range of movements, abnormalities of
joints.

224      NEUROLOGIC
— REFLEXES, ETC. To include reflexes, sensation, power, vestibular system —
balance, romberg test, etc.

225      PSYCHIATRIC
— To include appearance, appropriate mood/thought, unusual behaviour.

226      SKIN,
IDENTIFYING MARKS AND LYMPHATICS — To include inspection of skin; inspection,
palpation for lymphadenopathy, etc. Briefly describe scars, tattoos,
birthmarks, etc., which could be used for identification purposes.

227      GENERAL
SYSTEMIC — All other areas, systems and nutritional status.

228      NOTES
— Any notes, comments or abnormalities to be described — extra notes if required
on separate sheet of paper, signed and dated.

229      DISTANT
VISION — Each eye to be examined separately and then both together. First
without correction, then with spectacles (if used) and lastly with contact
lenses, if used. Record visual acuity in appropriate boxes. Visual acuity to
be tested with the appropriate chart for the distance.

230      INTERMEDIATE
VISION — Each eye to be examined separately and then both together. First
without correction, then with spectacles, if used, and lastly with contact
lenses, if used. Record visual acuity in appropriate boxes (Yes/No).

231      NEAR
VISION — Each eye to be examined separately and then both together. First
without correction, then with spectacles if used and lastly with contact
lenses, if used. Record visual acuity in appropriate boxes (Yes/No).

Note: Bifocal contact lenses and contact lenses
correcting for near vision only are not acceptable.

232      SPECTACLES
— Tick appropriate box signifying if spectacles are or are not worn by
applicant. If used, state type of lens and frame and use-distance.

233      CONTACT
LENSES — Tick appropriate box signifying if contact lenses are or are not
worn. If worn, state type from the following list; hard, soft, gas-permeable
or disposable.

313      COLOUR
VISION — Tick appropriate box signifying if applicant is a normal trichromat
or not. Indicate the colour vision testing methodology used and provide the
results.

234      HEARING
— Tick appropriate box to indicate hearing level ability as tested separately
in each ear at 2 m.

235      URINALYSIS
— State whether result of urinalysis is normal or not by ticking appropriate
box. If no abnormal constituents, state NIL in each appropriate box.

236      PULMONARY
FUNCTION — When required or on indication, state actual FEV1/FVC value
obtained in % and state if normal or not with reference to height, age, sex
and race.

237      HAEMOGLOBIN
— Enter actual haemoglobin test result and state units used. Then state
whether normal value or not, by ticking appropriate box.

238 to 244 inclusive: ACCOMPANYING REPORTS — One
box opposite each of these sections must be ticked. If the test is not
required and has not been performed, then tick the NOT PERFORMED box. If the
test has been performed (whether required or on indication) complete the
normal or abnormal box as appropriate. In the case of question 244, the number
of other accompanying reports must be stated.

247      AME
RECOMMENDATION — The applicant’s name, date of birth and reference number,
should be entered here in block capitals. The applicable class of medical
certificate should be indicated by a tick in the appropriate box. If a fit
assessment is recommended and a medical certificate has been issued, this
should be indicated in the appropriate box. An applicant may be recommended as
fit for a lower class of medical certificate (e.g. class 2), but also be
deferred or recommended as unfit for a higher class of medical certificate
(e.g. class 1). If an unfit recommendation is made, applicable Part MED/Part
ATCO.MED paragraph references should be entered. If an applicant is deferred
for further evaluation, the reason and the specialist or licensing authority
to whom the applicant is referred should be indicated.

248      COMMENTS,
LIMITATIONS, ETC. — The AME’s findings and assessment of any abnormality in
the history or examination, should be entered here. The AME should also state
any limitation required.

249      AME
DETAILS — The AME should sign the declaration, complete his/her name and
address in block capitals, contact details and lastly stamp the relevant
section with his/her designated AME stamp incorporating his/her AME number.

250      PLACE
AND DATE — The place (town or city) and the date of the aero-medical
examination should be entered here. The date of examination is the date of the
general examination and not the date of finalisation of the form. If the
aero-medical examination report is finalised on a different date, the date of
finalisation should be entered in section 248 as ‘Report finalised on ...’.

OPHTHALMOLOGY
EXAMINATION REPORT FORM

Complete this page fully
and in block capitals — Refer to instructions for completion.

MEDICAL IN CONFIDENCE

Applicant’s details

<table border="1" cellpadding="0" cellspacing="0" width="605">
<tr>
<td valign="top" width="189">
(1) Licensing authority:
</td>
<td colspan="3" valign="top" width="416">
(2) Medical certificate applied for: Class 1 
 o       Class 2  o       Class 3  o
</td>
</tr>
<tr>
<td valign="top" width="189">
(3) Surname:
</td>
<td colspan="2" valign="top" width="236">
(4) Previous surname(s):
</td>
<td valign="top" width="180">
(12) Application:        Initial   o
Revalidation/Renewal 
 o
</td>
</tr>
<tr>
<td valign="top" width="189">
(5) Forename(s):
</td>
<td valign="top" width="151">
(6) Date of birth:
</td>
<td valign="top" width="85">
(7) Sex:
Male    o
Female o
</td>
<td valign="top" width="180">
(13) Reference number:
</td>
</tr>
<tr>
<td colspan="4" valign="top" width="605">
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</v:rect>(301) Consent to release of medical information: I hereby authorise
 the release of all information contained in this report and any or all
 attachments to the AME and, where necessary, to the medical assessor of the
 licensing authority, recognising that these documents or electronically
 stored data, are to be used for completion of a medical assessment and will
 become and remain the property of the licensing authority, providing that I
 or my physician may have access to them according to national law. Medical
 confidentiality will be respected at all times.
---------------------------------------           --------------------------------------------------         ---------------------------------------------------
                     Date                                                 Signature of applicant                                      Signature of AME
</td>
</tr>
<tr height="0">
</tr>
</table>

<table border="1" cellpadding="0" cellspacing="0" width="605">
<tr>
<td valign="top" width="208">
(302) Examination category:
</td>
<td valign="top" width="397">
 (303)
 Ophthalmological history:
</td>
</tr>
<tr>
<td valign="top" width="208">
             Initial              
 o
</td>
<td valign="top" width="397">
</td>
</tr>
<tr>
<td valign="top" width="208">
             Revalidation   o
</td>
<td valign="top" width="397">
</td>
</tr>
<tr>
<td valign="top" width="208">
             Renewal          o
</td>
<td valign="top" width="397">
</td>
</tr>
<tr>
<td valign="top" width="208">
             Referral          o
</td>
<td valign="top" width="397">
</td>
</tr>
</table>

Clinical examination                                                                        Visual acuity

<table border="1" cellpadding="0" cellspacing="0" width="606">
<tr>
<td colspan="4" valign="top" width="189">
Check each item
</td>
<td width="47">
Normal
</td>
<td width="58">
Abnormal
</td>
<td valign="top" width="16">
</td>
<td colspan="5" valign="bottom" width="193">
(314) Distant vision
             Uncorrected
</td>
<td colspan="4" valign="top" width="103">
Spectacles
Contact 
 lenses
</td>
</tr>
<tr>
<td colspan="4" valign="top" width="189">
(304) Eyes, external &amp; eyelids
</td>
<td valign="top" width="47">
</td>
<td valign="top" width="58">
</td>
<td valign="top" width="16">
</td>
<td valign="top" width="68">
Right eye
</td>
<td valign="top" width="42">
</td>
<td colspan="3" valign="top" width="83">
Corrected to
</td>
<td colspan="2" valign="top" width="51">
</td>
<td colspan="2" valign="top" width="51">
</td>
</tr>
<tr>
<td colspan="4" rowspan="2" valign="top" width="189">
(305) Eyes, Exterior
(slit lamp, ophth.)
</td>
<td rowspan="2" valign="top" width="47">
</td>
<td rowspan="2" valign="top" width="58">
</td>
<td valign="top" width="16">
</td>
<td valign="top" width="68">
Left eye
</td>
<td valign="top" width="42">
</td>
<td colspan="3" valign="top" width="83">
Corrected to
</td>
<td colspan="2" valign="top" width="51">
</td>
<td colspan="2" valign="top" width="51">
</td>
</tr>
<tr>
<td valign="top" width="16">
</td>
<td valign="top" width="68">
Both eyes
</td>
<td valign="top" width="42">
</td>
<td colspan="3" valign="top" width="83">
Corrected to
</td>
<td colspan="2" valign="top" width="51">
</td>
<td colspan="2" valign="top" width="51">
</td>
</tr>
<tr>
<td colspan="4" valign="top" width="189">
(306) Eye position and motility
</td>
<td valign="top" width="47">
</td>
<td valign="top" width="58">
</td>
<td valign="top" width="16">
</td>
<td colspan="5" valign="top" width="193">
(315) Intermediate vision
             Uncorrected
</td>
<td colspan="4" valign="top" width="103">
Spectacles
Contact 
 lenses
</td>
</tr>
<tr>
<td colspan="4" valign="top" width="189">
(307) Visual fields
</td>
<td valign="top" width="47">
</td>
<td valign="top" width="58">
</td>
<td valign="top" width="16">
</td>
<td valign="top" width="68">
Right eye
</td>
<td valign="top" width="42">
</td>
<td colspan="3" valign="top" width="83">
Corrected to
</td>
<td colspan="2" valign="top" width="51">
</td>
<td colspan="2" valign="top" width="51">
</td>
</tr>
<tr>
<td colspan="4" valign="top" width="189">
(308) Pupillary reflexes
</td>
<td valign="top" width="47">
</td>
<td valign="top" width="58">
</td>
<td valign="top" width="16">
</td>
<td valign="top" width="68">
Left eye
</td>
<td valign="top" width="42">
</td>
<td colspan="3" valign="top" width="83">
Corrected to
</td>
<td colspan="2" valign="top" width="51">
</td>
<td colspan="2" valign="top" width="51">
</td>
</tr>
<tr>
<td colspan="4" valign="top" width="189">
(309) Fundi (Ophthalmoscopy)
</td>
<td valign="top" width="47">
</td>
<td valign="top" width="58">
</td>
<td valign="top" width="16">
</td>
<td valign="top" width="68">
Both eyes
</td>
<td valign="top" width="42">
</td>
<td colspan="3" valign="top" width="83">
Corrected to
</td>
<td colspan="2" valign="top" width="51">
</td>
<td colspan="2" valign="top" width="51">
</td>
</tr>
<tr>
<td valign="top" width="139">
(310) Convergence
</td>
<td colspan="3" valign="top" width="50">
cm
</td>
<td valign="top" width="47">
</td>
<td valign="top" width="58">
</td>
<td valign="top" width="16">
</td>
<td colspan="5" valign="top" width="193">
(316) Near vision
             Uncorrected
</td>
<td colspan="4" valign="top" width="103">
Spectacle
Contact 
 lenses
</td>
</tr>
<tr>
<td valign="top" width="139">
(311) Accommodation
</td>
<td colspan="3" valign="top" width="50">
D
</td>
<td valign="top" width="47">
</td>
<td valign="top" width="58">
</td>
<td valign="top" width="16">
</td>
<td valign="top" width="68">
Right eye
</td>
<td valign="top" width="42">
</td>
<td colspan="3" valign="top" width="83">
Corrected to
</td>
<td colspan="2" valign="top" width="51">
</td>
<td colspan="2" valign="top" width="51">
</td>
</tr>
<tr>
<td colspan="4" valign="top" width="189">
</td>
<td valign="top" width="47">
</td>
<td valign="top" width="58">
</td>
<td valign="top" width="16">
</td>
<td valign="top" width="68">
Left eye
</td>
<td valign="top" width="42">
</td>
<td colspan="3" valign="top" width="83">
Corrected to
</td>
<td colspan="2" valign="top" width="51">
</td>
<td colspan="2" valign="top" width="51">
</td>
</tr>
<tr>
<td colspan="6" valign="top" width="294">
(312) Ocular muscle balance (in
 prisme dioptres) 
</td>
<td valign="top" width="16">
</td>
<td valign="top" width="68">
Both eyes
</td>
<td valign="top" width="42">
</td>
<td colspan="3" valign="top" width="83">
Corrected to
</td>
<td colspan="2" valign="top" width="51">
</td>
<td colspan="2" valign="top" width="51">
</td>
</tr>
<tr>
<td colspan="2" valign="top" width="167">
Distant at 5m/6m
</td>
<td colspan="4" valign="top" width="127">
Near at 30–50 cm
</td>
<td valign="top" width="16">
</td>
<td colspan="2" valign="top" width="110">
</td>
<td colspan="3" valign="top" width="83">
</td>
<td colspan="2" valign="top" width="51">
</td>
<td colspan="2" valign="top" width="51">
</td>
</tr>
<tr>
<td colspan="2" valign="top" width="167">
Ortho
</td>
<td colspan="4" valign="top" width="127">
Ortho
</td>
<td valign="top" width="16">
</td>
<td colspan="2" valign="top" width="110">
(317) Refraction
</td>
<td valign="top" width="36">
Sph
</td>
<td colspan="3" valign="top" width="61">
Cylinder
</td>
<td colspan="2" valign="top" width="46">
Axis
</td>
<td valign="top" width="43">
Near (add)
</td>
</tr>
<tr>
<td colspan="2" valign="top" width="167">
Eso
</td>
<td colspan="4" valign="top" width="127">
Eso
</td>
<td valign="top" width="16">
</td>
<td colspan="2" valign="top" width="110">
Right eye
</td>
<td colspan="4" valign="top" width="97">
</td>
<td colspan="2" valign="top" width="46">
</td>
<td valign="top" width="43">
</td>
</tr>
<tr>
<td colspan="2" valign="top" width="167">
Exo
</td>
<td colspan="4" valign="top" width="127">
Exo
</td>
<td valign="top" width="16">
</td>
<td colspan="2" valign="top" width="110">
Left eye
</td>
<td colspan="4" valign="top" width="97">
</td>
<td colspan="2" valign="top" width="46">
</td>
<td valign="top" width="43">
</td>
</tr>
<tr>
<td colspan="2" valign="top" width="167">
Hyper
</td>
<td colspan="4" valign="top" width="127">
Hyper
</td>
<td valign="top" width="16">
</td>
<td colspan="9" valign="top" width="296">
Actual refraction examined
Spectacles prescription based
</td>
</tr>
<tr>
<td colspan="2" valign="top" width="167">
Cyclo
</td>
<td colspan="4" valign="top" width="127">
Cyclo
</td>
<td valign="top" width="16">
</td>
<td colspan="2" valign="top" width="110">
</td>
<td colspan="3" valign="top" width="83">
</td>
<td colspan="2" valign="top" width="51">
</td>
<td colspan="2" valign="top" width="51">
</td>
</tr>
<tr>
<td colspan="6" valign="top" width="294">
Tropia   
 Yes    No       Phoria         Yes        No 
</td>
<td valign="top" width="16">
</td>
<td colspan="4" valign="top" width="182">
(318) Spectacles  
</td>
<td colspan="5" valign="top" width="114">
(319) Contact lenses
</td>
</tr>
<tr>
<td colspan="6" valign="top" width="294">
Fusional reserve testing
Not performed        Normal        Abnormal
</td>
<td valign="top" width="16">
</td>
<td colspan="4" valign="top" width="182">
Yes  o      No  o
</td>
<td colspan="5" valign="top" width="114">
Yes  oNo  o
</td>
</tr>
<tr>
<td colspan="6" valign="top" width="294">
(313) Colour vision
</td>
<td valign="top" width="16">
</td>
<td colspan="4" valign="top" width="182">
Type:
</td>
<td colspan="5" valign="top" width="114">
Type:
</td>
</tr>
<tr>
<td colspan="3" valign="top" width="177">
Colour vision testing method/s:
</td>
<td colspan="3" valign="top" width="117">
</td>
<td valign="top" width="16">
</td>
<td colspan="4" valign="top" width="182">
</td>
<td colspan="5" valign="top" width="114">
</td>
</tr>
<tr>
<td colspan="3" valign="top" width="177">
Results:
</td>
<td colspan="2" valign="top" width="59">
</td>
<td valign="top" width="58">
</td>
<td valign="top" width="16">
</td>
<td colspan="9" valign="top" width="296">
(320) Intra-ocular pressure
</td>
</tr>
<tr>
<td colspan="6" valign="top" width="294">
Normal trichromat    Yes   o                 No  
 o
</td>
<td valign="top" width="16">
</td>
<td colspan="4" valign="top" width="182">
Right (mmHg)
</td>
<td colspan="5" valign="top" width="114">
Left (mmHg)
</td>
</tr>
<tr>
<td colspan="6" valign="top" width="294">
</td>
<td valign="top" width="16">
</td>
<td colspan="4" valign="top" width="182">
</td>
<td colspan="5" valign="top" width="114">
</td>
</tr>
<tr>
<td colspan="6" valign="top" width="294">
</td>
<td valign="top" width="16">
</td>
<td colspan="4" valign="top" width="182">
Method
</td>
<td colspan="5" valign="top" width="114">
Normal  o  Abnormal 
 o
</td>
</tr>
<tr height="0">
</tr>
</table>

(321) Ophthalmological remarks and
recommendation:

(322) Examiner’s declaration:

<table border="1" cellpadding="0" cellspacing="0" width="605">
<tr>
<td colspan="3" valign="top" width="605">
I hereby certify that I/my AME group have personally
 examined the applicant named on this medical examination report and that
 this report with any attachment embodies my findings completely and
 correctly.
</td>
</tr>
<tr>
<td valign="top" width="198">
(323) Place and date:
</td>
<td valign="top" width="237">
Ophth. examiner’s name and address: (block capitals)
</td>
<td valign="top" width="169">
AME or specialist stamp with No:
</td>
</tr>
<tr>
<td valign="top" width="198">
AME or specialist signature:
</td>
<td valign="top" width="237">
E-mail:
Telephone No:
Telefax No:
</td>
<td valign="top" width="169">
</td>
</tr>
</table>

INSTRUCTIONS FOR COMPLETION OF THE
OPHTHALMOLOGY EXAMINATION REPORT FORM

Writing should be legible and in block capitals
using a ball-point pen. Completion of this form by typing or printing is also
acceptable. If more space is required to answer any question, a plain sheet of
paper should be used, bearing the applicant’s name, the name and signature of
the AME or ophthalmology specialist performing the examination and the date of
signing. The following numbered instructions apply to the numbered headings on
the ophthalmology examination report form.

Failure to complete the medical examination report
form in full, as required, or to write legibly may result in non-acceptance of
the application in total and may lead to withdrawal of any medical certificate
issued. The making of false or misleading statements or the withholding of
relevant information by an examiner may result in criminal prosecution, denial
of an application or withdrawal of any medical certificate granted.

The AME or ophthalmology specialist performing the
examination should verify the identity of the applicant. The applicant should
then be requested to complete the sections 1, 2, 3, 4, 5, 6, 7, 12 and 13 on
the form and then sign and date the consent to release of medical information
(section 301) with the examiner countersigning as witness.

302      EXAMINATION
CATEGORY — Tick appropriate box.

Initial — Initial examination for either class 1 or
2 or 3; also initial examination for upgrading from class 2 to 1 (notate
‘upgrading’ in section 303).

Renewal/Revalidation — Subsequent comprehensive
ophthalmological examinations (due to refractive error).

Special referral — NON-ROUTINE examination for
assessment of an ophthalmological symptom or finding.

303      OPHTHALMOLOGICAL
HISTORY — Detail here any history of note or reasons for special referral.

304 to 309 inclusive: CLINICAL EXAMINATION — These
sections together cover the general clinical examination and each of the
sections should be marked (with a tick) as normal or abnormal. Any abnormal
findings or comments on findings should be entered in section 321.

310      CONVERGENCE
— Enter near point of convergence in cm, as measured using RAF near point rule
or equivalent. Tick whether normal or abnormal. Any abnormal findings or
comments on findings should be entered in section 321.

311      ACCOMMODATION
— Enter measurement recorded in dioptres using RAF near point rule or
equivalent. Tick whether normal or abnormal. Any abnormal findings or comments
on findings should be entered in section 321.

312      OCULAR
MUSCLE BALANCE — Ocular muscle balance is tested at distant 5 or 6 m and near
at 30–50 cm and results recorded. Presence of tropia or phoria must be entered
accordingly and also whether fusional reserve testing was NOT performed and if
performed whether normal or not.

313      COLOUR
VISION —Tick appropriate box signifying if applicant is a normal trichromat or
not. Indicate the colour vision testing methodology used and provide results.

314–316 VISUAL ACUITY TESTING AT 5 m/6m, 1m and
30–50cm — Record actual visual acuity obtained in appropriate boxes. If
correction not worn nor required, put line through corrected vision boxes.
Distant visual acuity to be tested at either 5 m or 6 m with the appropriate
chart for that distance.

317      REFRACTION
— Record results of refraction. Indicate also whether for class 2 applicants,
refraction details are based upon spectacle prescription.

318      SPECTACLES
— Tick appropriate box signifying if spectacles are or are not worn by
applicant. If used, state whether unifocal, bifocal, varifocal or look-over.

319      CONTACT
LENSES — Tick appropriate box signifying if contact lenses are or are not
worn. If worn, state type from the following list; hard, soft, gas-permeable,
disposable.

320      INTRA-OCULAR
PRESSURE — Enter intra-ocular pressure recorded for right and left eyes and
indicate whether normal or not. Also indicate method used —applanation, air,
etc.

321      OPHTHALMOLOGICAL
REMARKS AND RECOMMENDATION — Enter here all remarks, abnormal findings and
assessment results. Also enter any limitations recommended. If there is any
doubt about findings or recommendations, the examiner may contact the medical
assessor for advice before finalising the report form.

322      OPHTHALMOLOGY
EXAMINER’S DETAILS — The ophthalmology examiner must sign the declaration,
complete his/her name and address in block capitals, contact details and
lastly stamp the report with his/her designated stamp incorporating his/her
AME or specialist number.

323      PLACE
AND DATE — Enter the place (town or city) and the date of examination. The
date of examination is the date of the clinical examination and not the date
of finalisation of form. If the ophthalmology examination report is finalised
on a different date, enter date of finalisation on section 321 as ‘Report
finalised on...’.

OTORHINOLARYNGOLOGY EXAMINATION REPORT
FORM

Complete this page fully and in block capitals — Refer to
instructions for completion.

MEDICAL IN CONFIDENCE

Applicant’s details

<table border="1" cellpadding="0" cellspacing="0" width="605">
<tr>
<td valign="top" width="180">
(1) Licensing authority:
</td>
<td colspan="3" valign="top" width="425">
(2) Medical certificate applied for: class 1 
 o        class 2  o       class 3  o
</td>
</tr>
<tr>
<td valign="top" width="180">
(3) Surname:
</td>
<td colspan="2" valign="top" width="246">
(4) Previous surname(s):
</td>
<td valign="top" width="180">
(12) Application:        Initial  o
Revalidation/Renewal o
</td>
</tr>
<tr>
<td valign="top" width="180">
(5) Forename(s):
</td>
<td valign="top" width="151">
(6) Date of birth:
</td>
<td valign="top" width="94">
(7) Sex:
Male    o
Female o
</td>
<td valign="top" width="180">
(13) Reference number:
</td>
</tr>
<tr>
<td colspan="4" valign="top" width="605">
(401) Consent to release of medical
 information: I hereby authorise the release of all information
 contained in this report and any or all attachments to the AME and, where
 necessary, to the medical assessor of the licensing authority, recognising
 that these documents, or any electronically stored data, are to be used for
 completion of a medical assessment and will become and remain the property
 of the licensing authority, providing that I or my physician may have access
 to them according to national law. Medical confidentiality will be respected
 at all times.
------------------------------------  -----------------------------------------------------    --------------------------------------------------
                    Date                                        Signature of applicant                                    Signature of AME
</td>
</tr>
<tr height="0">
</tr>
</table>

<table border="1" cellpadding="0" cellspacing="0" width="605">
<tr>
<td valign="top" width="236">
(402) Examination category:
</td>
<td valign="top" width="369">
(403) Otorhinolaryngological history:
</td>
</tr>
<tr>
<td valign="top" width="236">
</td>
<td valign="top" width="369">
</td>
</tr>
<tr>
<td valign="top" width="236">
             Initial                                       o
             Revalidation/renewal            o
</td>
<td valign="top" width="369">
</td>
</tr>
<tr>
<td valign="top" width="236">
             Referral                                   o
</td>
<td valign="top" width="369">
</td>
</tr>
</table>

Clinical examination

<table border="1" cellpadding="0" cellspacing="0" width="605">
<tr>
<td colspan="3" valign="top" width="246">
Check each item
</td>
<td colspan="2" valign="top" width="48">
Normal
</td>
<td valign="top" width="59">
Abnormal
</td>
<td valign="top" width="16">
</td>
<td colspan="11" valign="top" width="236">
(419) Pure tone audiometry
</td>
</tr>
<tr>
<td colspan="3" valign="top" width="246">
(404) Head, face, neck, scalp
</td>
<td colspan="2" valign="top" width="48">
</td>
<td valign="top" width="59">
</td>
<td valign="top" width="16">
</td>
<td colspan="11" valign="top" width="236">
dB HL (hearing level)
</td>
</tr>
<tr>
<td colspan="3" valign="top" width="246">
(405) Buccal cavity, teeth
</td>
<td colspan="2" valign="top" width="48">
</td>
<td valign="top" width="59">
</td>
<td valign="top" width="16">
</td>
<td valign="top" width="42">
Hz
</td>
<td colspan="5" valign="top" width="90">
Right ear
</td>
<td colspan="5" valign="top" width="104">
Left ear
</td>
</tr>
<tr>
<td colspan="3" valign="top" width="246">
(406) Pharynx
</td>
<td colspan="2" valign="top" width="48">
</td>
<td valign="top" width="59">
</td>
<td valign="top" width="16">
</td>
<td width="42">
250
</td>
<td colspan="5" valign="top" width="90">
</td>
<td colspan="5" valign="top" width="104">
</td>
</tr>
<tr>
<td colspan="3" valign="top" width="246">
(407) Nasal passages and naso-pharynx
</td>
<td colspan="2" valign="top" width="48">
</td>
<td valign="top" width="59">
</td>
<td valign="top" width="16">
</td>
<td width="42">
500
</td>
<td colspan="5" valign="top" width="90">
</td>
<td colspan="5" valign="top" width="104">
</td>
</tr>
<tr>
<td colspan="3" valign="top" width="246">
(incl. anterior rhinoscopy)
</td>
<td colspan="2" valign="top" width="48">
</td>
<td valign="top" width="59">
</td>
<td valign="top" width="16">
</td>
<td width="42">
1000
</td>
<td colspan="5" valign="top" width="90">
</td>
<td colspan="5" valign="top" width="104">
</td>
</tr>
<tr>
<td colspan="3" valign="top" width="246">
(408) Vestibular system incl. Romberg test
</td>
<td colspan="2" valign="top" width="48">
</td>
<td valign="top" width="59">
</td>
<td valign="top" width="16">
</td>
<td width="42">
2000
</td>
<td colspan="5" valign="top" width="90">
</td>
<td colspan="5" valign="top" width="104">
</td>
</tr>
<tr>
<td colspan="3" valign="top" width="246">
(409) Speech/voice
</td>
<td colspan="2" valign="top" width="48">
</td>
<td valign="top" width="59">
</td>
<td valign="top" width="16">
</td>
<td width="42">
3000
</td>
<td colspan="5" valign="top" width="90">
</td>
<td colspan="5" valign="top" width="104">
</td>
</tr>
<tr>
<td colspan="3" valign="top" width="246">
(410) Sinuses
</td>
<td colspan="2" valign="top" width="48">
</td>
<td valign="top" width="59">
</td>
<td valign="top" width="16">
</td>
<td width="42">
4000
</td>
<td colspan="5" valign="top" width="90">
</td>
<td colspan="5" valign="top" width="104">
</td>
</tr>
<tr>
<td colspan="3" valign="top" width="246">
(411) Ext. acoustic meati, tympanic membranes
</td>
<td colspan="2" valign="top" width="48">
</td>
<td valign="top" width="59">
</td>
<td valign="top" width="16">
</td>
<td width="42">
6000
</td>
<td colspan="5" valign="top" width="90">
</td>
<td colspan="5" valign="top" width="104">
</td>
</tr>
<tr>
<td colspan="3" valign="top" width="246">
(412) Pneumatic otoscopy
</td>
<td colspan="2" valign="top" width="48">
</td>
<td valign="top" width="59">
</td>
<td valign="top" width="16">
</td>
<td width="42">
8000
</td>
<td colspan="5" valign="top" width="90">
</td>
<td colspan="5" valign="top" width="104">
</td>
</tr>
<tr>
<td colspan="3" valign="top" width="246">
(413) Impedance tympanometry including
</td>
<td colspan="2" valign="top" width="48">
</td>
<td valign="top" width="59">
</td>
<td valign="top" width="16">
</td>
<td valign="top" width="42">
</td>
<td colspan="5" valign="top" width="90">
</td>
<td colspan="5" valign="top" width="104">
</td>
</tr>
<tr>
<td colspan="3" valign="top" width="246">
Valsalva manoeuvre (initial only)
</td>
<td colspan="2" valign="top" width="48">
</td>
<td valign="top" width="59">
</td>
<td valign="top" width="16">
</td>
<td colspan="11" valign="top" width="236">
(420) Audiogram
</td>
</tr>
<tr>
<td colspan="3" valign="top" width="246">
</td>
<td valign="top" width="22">
</td>
<td valign="top" width="26">
</td>
<td valign="top" width="59">
</td>
<td valign="top" width="16">
</td>
<td valign="top" width="42">
</td>
<td colspan="2" valign="top" width="34">
</td>
<td colspan="8" valign="top" width="161">
o = Right      – – –  = Air 
 x = Left       .......... = Bone
</td>
</tr>
<tr>
<td valign="top" width="185">
</td>
<td colspan="2" valign="top" width="62">
</td>
<td colspan="2" valign="top" width="48">
</td>
<td valign="top" width="59">
</td>
<td valign="top" width="16">
</td>
<td valign="top" width="42">
</td>
<td valign="top" width="24">
</td>
<td colspan="2" valign="top" width="24">
</td>
<td valign="top" width="24">
</td>
<td colspan="2" valign="top" width="24">
</td>
<td valign="top" width="24">
</td>
<td valign="top" width="24">
</td>
<td valign="top" width="24">
</td>
<td valign="top" width="24">
</td>
</tr>
<tr>
<td rowspan="2" valign="top" width="185">
Additional 
 testing
(if indicated)
</td>
<td colspan="2" rowspan="2" valign="bottom" width="62">
Not
performed
</td>
<td colspan="2" valign="top" width="48">
Normal
</td>
<td valign="top" width="59">
Abnormal
</td>
<td valign="top" width="16">
</td>
<td valign="bottom" width="42">
dB/HL
</td>
<td valign="top" width="24">
</td>
<td colspan="2" valign="top" width="24">
</td>
<td valign="top" width="24">
</td>
<td colspan="2" valign="top" width="24">
</td>
<td valign="top" width="24">
</td>
<td valign="top" width="24">
</td>
<td valign="top" width="24">
</td>
<td valign="top" width="24">
</td>
</tr>
<tr>
<td colspan="2" valign="top" width="48">
</td>
<td valign="top" width="59">
</td>
<td valign="top" width="16">
</td>
<td width="42">
–10
</td>
<td valign="top" width="24">
</td>
<td colspan="2" valign="top" width="24">
</td>
<td valign="top" width="24">
</td>
<td colspan="2" valign="top" width="24">
</td>
<td valign="top" width="24">
</td>
<td valign="top" width="24">
</td>
<td valign="top" width="24">
</td>
<td valign="top" width="24">
</td>
</tr>
<tr>
<td valign="top" width="185">
(414) Speech audiometry
</td>
<td colspan="2" valign="top" width="62">
</td>
<td colspan="2" valign="top" width="48">
</td>
<td valign="top" width="59">
</td>
<td valign="top" width="16">
</td>
<td width="42">
    0
</td>
<td valign="top" width="24">
</td>
<td colspan="2" valign="top" width="24">
</td>
<td valign="top" width="24">
</td>
<td colspan="2" valign="top" width="24">
</td>
<td valign="top" width="24">
</td>
<td valign="top" width="24">
</td>
<td valign="top" width="24">
</td>
<td valign="top" width="24">
</td>
</tr>
<tr>
<td valign="top" width="185">
(415) Posterior rhinoscopy
</td>
<td colspan="2" valign="top" width="62">
</td>
<td colspan="2" valign="top" width="48">
</td>
<td valign="top" width="59">
</td>
<td valign="top" width="16">
</td>
<td width="42">
  10
</td>
<td valign="top" width="24">
</td>
<td colspan="2" valign="top" width="24">
</td>
<td valign="top" width="24">
</td>
<td colspan="2" valign="top" width="24">
</td>
<td valign="top" width="24">
</td>
<td valign="top" width="24">
</td>
<td valign="top" width="24">
</td>
<td valign="top" width="24">
</td>
</tr>
<tr>
<td rowspan="2" valign="top" width="185">
(416) EOG; spontaneous and positional nystagmus
</td>
<td colspan="5" rowspan="2" valign="top" width="168">
</td>
<td valign="top" width="16">
</td>
<td width="42">
  20
</td>
<td valign="top" width="24">
</td>
<td colspan="2" valign="top" width="24">
</td>
<td valign="top" width="24">
</td>
<td colspan="2" valign="top" width="24">
</td>
<td valign="top" width="24">
</td>
<td valign="top" width="24">
</td>
<td valign="top" width="24">
</td>
<td valign="top" width="24">
</td>
</tr>
<tr>
<td valign="top" width="16">
</td>
<td width="42">
  30
</td>
<td valign="top" width="24">
</td>
<td colspan="2" valign="top" width="24">
</td>
<td valign="top" width="24">
</td>
<td colspan="2" valign="top" width="24">
</td>
<td valign="top" width="24">
</td>
<td valign="top" width="24">
</td>
<td valign="top" width="24">
</td>
<td valign="top" width="24">
</td>
</tr>
<tr>
<td valign="top" width="185">
(417) Differential caloric test or
</td>
<td colspan="5" rowspan="2" valign="top" width="168">
</td>
<td valign="top" width="16">
</td>
<td width="42">
  40
</td>
<td valign="top" width="24">
</td>
<td colspan="2" valign="top" width="24">
</td>
<td valign="top" width="24">
</td>
<td colspan="2" valign="top" width="24">
</td>
<td valign="top" width="24">
</td>
<td valign="top" width="24">
</td>
<td valign="top" width="24">
</td>
<td valign="top" width="24">
</td>
</tr>
<tr>
<td valign="top" width="185">
vestibular autorotation test
</td>
<td valign="top" width="16">
</td>
<td width="42">
  50
</td>
<td valign="top" width="24">
</td>
<td colspan="2" valign="top" width="24">
</td>
<td valign="top" width="24">
</td>
<td colspan="2" valign="top" width="24">
</td>
<td valign="top" width="24">
</td>
<td valign="top" width="24">
</td>
<td valign="top" width="24">
</td>
<td valign="top" width="24">
</td>
</tr>
<tr>
<td rowspan="2" valign="top" width="185">
(418) Mirror or fibre laryngoscopy
</td>
<td colspan="5" rowspan="2" valign="top" width="168">
</td>
<td valign="top" width="16">
</td>
<td width="42">
  60
</td>
<td valign="top" width="24">
</td>
<td colspan="2" valign="top" width="24">
</td>
<td valign="top" width="24">
</td>
<td colspan="2" valign="top" width="24">
</td>
<td valign="top" width="24">
</td>
<td valign="top" width="24">
</td>
<td valign="top" width="24">
</td>
<td valign="top" width="24">
</td>
</tr>
<tr>
<td valign="top" width="16">
</td>
<td width="42">
  70
</td>
<td valign="top" width="24">
</td>
<td colspan="2" valign="top" width="24">
</td>
<td valign="top" width="24">
</td>
<td colspan="2" valign="top" width="24">
</td>
<td valign="top" width="24">
</td>
<td valign="top" width="24">
</td>
<td valign="top" width="24">
</td>
<td valign="top" width="24">
</td>
</tr>
<tr>
<td valign="top" width="185">
</td>
<td colspan="2" valign="top" width="62">
</td>
<td colspan="3" width="106">
</td>
<td valign="top" width="16">
</td>
<td width="42">
  80
</td>
<td valign="top" width="24">
</td>
<td colspan="2" valign="top" width="24">
</td>
<td valign="top" width="24">
</td>
<td colspan="2" valign="top" width="24">
</td>
<td valign="top" width="24">
</td>
<td valign="top" width="24">
</td>
<td valign="top" width="24">
</td>
<td valign="top" width="24">
</td>
</tr>
<tr>
<td colspan="6" valign="top" width="353">
(421) Otorhinolaryngology remarks and recommendation:
</td>
<td valign="top" width="16">
</td>
<td width="42">
90
</td>
<td valign="top" width="24">
</td>
<td colspan="2" valign="top" width="24">
</td>
<td valign="top" width="24">
</td>
<td colspan="2" valign="top" width="24">
</td>
<td valign="top" width="24">
</td>
<td valign="top" width="24">
</td>
<td valign="top" width="24">
</td>
<td valign="top" width="24">
</td>
</tr>
<tr>
<td colspan="6" rowspan="4" valign="top" width="353">
</td>
<td valign="top" width="16">
</td>
<td width="42">
100
</td>
<td valign="top" width="24">
</td>
<td colspan="2" valign="top" width="24">
</td>
<td valign="top" width="24">
</td>
<td colspan="2" valign="top" width="24">
</td>
<td valign="top" width="24">
</td>
<td valign="top" width="24">
</td>
<td valign="top" width="24">
</td>
<td valign="top" width="24">
</td>
</tr>
<tr>
<td valign="top" width="16">
</td>
<td width="42">
110
</td>
<td valign="top" width="24">
</td>
<td colspan="2" valign="top" width="24">
</td>
<td valign="top" width="24">
</td>
<td colspan="2" valign="top" width="24">
</td>
<td valign="top" width="24">
</td>
<td valign="top" width="24">
</td>
<td valign="top" width="24">
</td>
<td valign="top" width="24">
</td>
</tr>
<tr>
<td valign="top" width="16">
</td>
<td width="42">
120
</td>
<td valign="top" width="24">
</td>
<td colspan="2" valign="top" width="24">
</td>
<td valign="top" width="24">
</td>
<td colspan="2" valign="top" width="24">
</td>
<td valign="top" width="24">
</td>
<td valign="top" width="24">
</td>
<td valign="top" width="24">
</td>
<td valign="top" width="24">
</td>
</tr>
<tr>
<td valign="top" width="16">
</td>
<td colspan="11" valign="top" width="236">
Hz     
 250  500  1000  2000  3000 
 4000  6000  8000
</td>
</tr>
<tr>
<td colspan="18" valign="top" width="605">
(422) Examiner’s
 declaration:
</td>
</tr>
<tr>
<td colspan="18" valign="top" width="605">
I
 hereby certify that I/my AME group have personally examined the applicant
 named on this medical examination report and that this report with any
 attachment embodies my findings completely and correctly.
</td>
</tr>
<tr>
<td colspan="2" valign="top" width="208">
(423) Place and date:
</td>
<td colspan="7" valign="top" width="227">
ORL examiner’s name and address: (block capitals)
</td>
<td colspan="9" valign="top" width="170">
AME or specialist stamp with No: 
</td>
</tr>
<tr>
<td colspan="2" valign="top" width="208">
</td>
<td colspan="7" valign="top" width="227">
</td>
<td colspan="9" valign="top" width="170">
</td>
</tr>
<tr>
<td colspan="2" valign="top" width="208">
AME or specialist signature:
</td>
<td colspan="7" valign="top" width="227">
</td>
<td colspan="9" valign="top" width="170">
</td>
</tr>
<tr>
<td colspan="2" valign="top" width="208">
</td>
<td colspan="7" valign="top" width="227">
E-mail:
Telephone No:
Telefax No:
</td>
<td colspan="9" valign="top" width="170">
</td>
</tr>
<tr height="0">
</tr>
</table>

INSTRUCTIONS FOR COMPLETION OF THE
OTORHINOLARYNGOLOGY EXAMINATION REPORT FORM

Writing should be legible and in block capitals
using a ball-point pen. Completion of this form by typing or printing is also
acceptable. If more space is required to answer any question, a plain sheet of
paper should be used, bearing the applicant’s name, the name and signature of
the AME or otorhinolaryngology specialist performing the examination and the
date of signing. The following numbered instructions apply to the numbered
headings on the otorhinolaryngology examination report form.

The AME or otorhinolaryngology specialist
performing the examination should verify the identity of the applicant. The
applicant should then be requested to complete the sections 1, 2, 3, 4, 5, 6,
7, 12 and 13 on the form and then sign and date the consent to release of
medical information (section 401) with the examiner countersigning as witness.

402      EXAMINATION
CATEGORY — Tick appropriate box.

Initial — Initial examination for class 1 or class
3; also initial examination for upgrading from class 2 to 1 or 3 (notate
‘upgrading’ in section 403).

Referral — NON-ROUTINE examination for assessment
of an ORL symptom or finding.

403      OTORHINOLARYNGOLOGICAL
HISTORY — Detail here any history of note or reasons for referral.

404–413 inclusive: CLINICAL EXAMINATION — These
sections together cover the general clinical examination and each of the
sections should be marked (with a tick) as normal or abnormal. Any abnormal
findings or comments on findings should be entered in section 421.

414–418 inclusive: ADDITIONAL TESTING — These tests
are only required to be performed if indicated by history or clinical findings
and are not routinely required. For each test one of the boxes must be
completed — if the test is not performed then tick that box — if the test has
been performed then tick the appropriate box for a normal or abnormal result.
All remarks and abnormal findings should be entered in section 421.

419      PURE
TONE AUDIOMETRY — Complete figures for dB HL (hearing level) in each ear at
all listed frequencies.

420      AUDIOGRAM
— Complete audiogram from figures as listed in section 419.

421      OTORHINOLARYNGOLOGY
REMARKS AND RECOMMENDATION — Enter here all remarks, abnormal findings and
assessment results. Also enter any limitations recommended. If there is any
doubt about findings or recommendations the examiner may contact the medical
assessor for advice before finalising the report form.

422      OTORHINOLARYNGOLOGY
EXAMINER’S DETAILS — The otorhinolaryngology examiner must sign the
declaration, complete his/her name and address in block capitals, contact
details and lastly stamp the report with his/her designated stamp
incorporating his/her AME or specialist number.

423      PLACE
AND DATE — Enter the place (town or city) and the date of examination. The
date of examination is the date of the clinical examination and not the date
of finalisation of form. If the ORL examination report is finalised on a
different date, enter date of finalisation in section 421 as ‘Report finalised
on...’.